Enter your name and address

here

1. Public servants full legal name: ___________________________________________

2. ID/Badge Number: ___________________________________________________
3. Name of Agency: _____________________________________________________
Agency Address: _____________________________________________________
City, State and Zip: ___________________________________________________
Agency Phone Number: ________________________________________________
Supervisors Name: ___________________________________________________
Supervisors Phone Number: _____________________________________________
4. Public servants Bonding Agency: __________________________________________
Bond Number: _______________________________________________________
5. Public servants Bonding Agency/Surety Agency address: __________________________
City, State and Zip: ____________________________________________________
Bonding Agency/Surety Agency Phone Number: ________________________________

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6. To complete this form, you as a public servant, have to provide a copy of your oath to uphold the
Constitution of these united states.
Will you provide a copy of your oath?
Yes

No

(Circle one

7. Will you, as a public servant, uphold the Constitution of these united states?
Yes

No

(Circle one)

8. Will you, as a public servant, defend the Constitution of these united states from enemies foreign and
domestic, including from any illegally obtained, ineligible person in office?
Yes

No

(Circle one)

9. Did you purchase Bond Insurance/Surety Insurance for yourself?

Yes

No

(Circle one)

10. If you did not purchase Bond Insurance/Surety Insurance for yourself, did your Agency purchase it for
you?
Yes

No

(Circle one)

Thank you. You have completed the Public Servant Questionnaire.

Please sign below and attach a copy of your Oath of Office to the Constitution of these united states where the
Constitution is supreme and the Sheriff is the supreme law of the land.
I hereby sign and affirm under the penalty of perjury that the answers are true and correct in every particular
instance.

Printed Name of Public Servant: _____________________________________

Signature of Public Servant: ________________________________________
Date: _______________

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